Issues of Concern
Whereas moral instruction dates to Egyptian writings dating to before 2000 BCE, the first recorded systematic approach to defining a set of moral behaviors (ethics) derived from logic belongs to Aristotle (384-322 BCE). He referred to his work as the "ethikos," which means the "customs." The word denotes the concept of "habitual character and disposition." Multiple other Greek writers (such as Thucydides (c. 460-400 BCE), Plato (c. 426-347 BCE), and Luke (c. first century CE) also used this word.
Aristotle, an early authority on legal theory and biology, based his ethics system on a rational defense of what behavior was appropriate or inappropriate with practical intent, specifically to improve the quality of human lives. His principal concern was the nature of human well-being.
Evolution of Ethics
Concepts on the nature and function of ethics continue to evolve. Whereas the study of ethics (including Aristotle's) always attempts to distinguish good from bad, the concept of ethics among laypersons has become associated with the connotations of distinguishing right from wrong (and starting in the 1300s CE of distinguishing virtue from evil). Ethical evolution, like the evolution of many other disciplines, particularly the field of law, often starts as a reaction to a new event (a human action or inaction) that an author considers unacceptable. Although the action/inaction involves specific circumstances (such as time, place, and views of the people involved), the reaction attempts to establish that the action/inaction shall thenceforth become unacceptable for others in circumstances potentially very different from the original event.
Many factors, such as economics, affect a society's ethics in a manner akin to a feedback loop (or yin-yang), particularly with respect to laws and other forms of enforced policies. Ethicists' views that policymakers support eventually lead to the creation of a policy. The policy eventually leads to a dilemma, then a reaction to the dilemma, and then a new or revisited commentary by ethicists regarding what action or inaction is acceptable. The cycle repeats. Thus, ethical principles follow traceable lines of historical events and persons that have prevailed in influence. Looking at the history of an ethical principle (or law) can provide an understanding of why the ethical principle has risen to prominence (or why a law exists) and may enable a practical basis for accepting or rejecting it. This evolution of ethics and policy results in a potential source of HCP conflict, such as when a HCP trained in more current ethical concepts and policy disagrees with a HCP who believes in more dated ones (e.g., paternalism). Medical ethics principles evolve intertwined with principles in other fields of ethics.
Ethics as a Systematic Study
Ethics comprises numerous overlapping subdisciplines. Medical ethics can be classified as a subdivision of applied ethics, but it functions dependently on the following subdivisions of ethics as well (this list is not intended to be all-inclusive):
- Descriptive ethics: How do people behave?
- Normative ethics: How ought people to behave (to do good)?
- Meta-ethics: What is good behavior? How can we tell what is good from what is bad?
- Applied ethics: How do we apply descriptive, normative, and meta-ethics conclusions to real-life situations?
- Virtue ethics: How does a person gain the skills and knowledge to be virtuous and to do good?
- Group ethics: What factors enable and inhibit individuals from working together to do good? Is there one set of behaviors that yields the greatest likelihood of prosperity for a particular group?
Just as the application of knowledge in a branch of surgery can improve by understanding aspects of other surgical disciplines, the application of medical ethics can improve by understanding aspects of these other ethical subdivisions. Conversely, limited awareness of ethical principles and hierarchies can set up a HCP to conclude that "there is no right answer" for a situation in which a confident best answer could otherwise emerge. For example, it was a grasp of Aristotle's non-medical virtue ethics from the 300s BCE that enabled Thomas Aquinas (1225-1274; not a HCP) to propose the Principle of Double Effect, which is used by HCPs in clinical practice today.
When, where, who, and what are relatively easy questions to answer. How and why are the harder questions. Metaphysics, epistemology, history, and the "hard" sciences address how. In their most ambitious form, ethics, theology, and logic also attempt to address why.
Without the exploration of the why, a HCP has limited ability to apply ethical concepts to new, varied, and complex situations. HCPs who truly want to understand and apply ethics must be simultaneously like a child repeatedly asking the next why and a teacher continuing to supply an ever more cogent answer.
Authority in Ethics
An explanation for "why" that adults give children is "because I said so." This suffices only if the child holds the adult to have a satisfactory position of authority. It is practical when having a dialogue with yourself, with patients, or with others regarding what is or is not ethical to share and apply the written and unwritten opinions of all relevant authorities to reach a satisfactory consensus.
Thomas Hobbes (1588-1679), the "father of Western political philosophy." His ideas spurred the creation of lists of "inalienable rights" of persons, and he also discussed the functions of authority in society. However, America's founding fathers rejected Hobbes' idea that government can have absolute power, holding it to be "self-evident" truth that:
- Authority is not in and of itself adequate for establishing what is ethical.
- An ethical principle raised by a person in free speech may trump authority for authority's sake.
As with scientific truth, where beliefs developed from "experience" are considered to be the worst level of evidence, deferring to "experience" or "years in the business" is not a reliable way to achieve the best decision in ethics.
Nevertheless, a shortcut to not having to think through an ethical dilemma is to refer to what a common/shared authority has already said. From laws to policies, the following list serves as a relative weighting of authority on medical policy (in decreasing order) for American HCPs that may help a HCP determine a course of action.
- US law (statutory law, common laws, executive law)
- State law (same as above; potentially useful even from another state if one's state has no contradictory law)
- National policy issued for HCPs regardless of type (AMA/AOA policy)
- National policy issued for a specified type of HCP (board/society of practice or ACGME policy)
- Local policy issued for HCPs regardless of type (hospital policy)
- Local policy issued for a specified type of HCP (department or training program policy)
In a real ethical dilemma, if none of the authorities listed above provides what seems to be adequate guidance, then HCPs can turn to authorities from the Great Conversation. The Great Conversation refers to how voices of the past, like Aristotle and Hobbes, shared ideas that ring true across time and place and influence people of later generations, which includes practical matters affecting the health care of millions of people today. For example, Harry Blackmun (1908-1999), the justice writing the majority opinion in the 1973 Roe vs. Wade trial, justified his decision to all the world, not based primarily on prior American law, but based on the views of Aristotle, Plato, and Jewish and Christian non-scriptural/post-scriptural writers. Further demonstration that law is not always the highest authority in medical ethics: the ACP code of ethics committee, which attorney chairs, states, "Medical and professional ethics often establish positive duties (that is, what one should do) to a greater extent than the law."
Medical Ethics and Objectivity
On the one hand, Aristotle stipulated that an all-encompassing system of ethics cannot be condensed to precise proofs that demonstrate that action holds true in every situation. On the other hand, he stated that some actions should never be taken (exemplifying objective ethics, discussed below). Returning to the comparison of applied ethics with the law, a functional ideal for both systems is that decisions derived from meta-ethics and normative ethics are made and enforced while maintaining impartiality for persons with one particular characteristic versus another as much as possible.
Ethics and Science
On the one hand, science can "improve" understanding and use of ethics. Some hypotheses and patterns in ethics can be studied using the scientific method. The dependent variable of persons' moral decisions can be assessed after exposing them to an independent variable in a randomized fashion. To a degree, persons' beliefs and behaviors can be quantified. Objectivity is a goal shared by science and ethics (discussed below).
On the other hand, "science" can be a hindrance to the original goal of ethics (i.e., to improve quality of life). Scientific advances causing problems with the quality of life is a common theme that science fiction movies use and that many laws and policies (such as those of the AMA) battle against. Setting aside the intent of science and contemplating the method of science only, the latter also may be of no aid. Sometimes the scientific method explains a cause and effect relationship, but often it does not and results in more questions than answers, similar to what can occur when mulling over an ethical dilemma. Applying the scientific method may not prove that one theory or course of action is superior to another. How a scientist develops and conducts an experiment is subjective and variable. How scientists interpret and apply facts varies. Much of the work passed off by persons labeled as "scientists" are observational (i.e., it does not apply the actual scientific method at all) or violates David Hume's (1711-1776) is/ought problem, which warns against laying out observations using descriptive terms and then concluding with unsubstantiated prescriptive terms.
So-called objective ethics (also called ethical absolutism but distinct from "objectivist ethics" or "ethical objectivism") is the attempt to create a set of ethical rules that (almost) always holds true. For an ethical behavior to be truly objective, it must depend neither on values nor beliefs but must depend entirely on reason (logic) and observable true statements. An observable true statement is one that can be shown to be true in the way the concept in the sentence "the sun is larger than the earth" can be shown to be true. Epistemology is the study of how a person can know something is true and is beyond this article's scope.
Ways to improve objectivity in medical ethics:
- Address the issue as if the decision needs to be made only with the motivation to serve the good of the person primarily affected by the decision; i.e., the decision-maker has
- no self-interest in the outcome (is impartial) or
- no knowledge of the actual outcome of the decision (similar to "blinding" in a blinded experiment).
- Alternatively (or additionally), address the issue as if the decision-maker is the one who would be the one experiencing the primary outcome of the decision. The "father of duty ethics," Immanuel Kant (1724-1804), used both of these tactics.
- Decide in such a way that the choice does apply or could apply to many circumstances/persons over many time points or instances. This approach is in contrast to a more subjective alternative, which applies a decision only to one or several circumstances/persons or over a few time points or instances. This concept is akin to using a mathematical algorithm designed to increase the odds of achieving the desired outcome over many instances at the possible sacrifice of achieving the desired outcome for a particular instance.
- Define a marker/point of reference to serve as an objective standard. An example from science is how a unit for measuring temperature was defined as the difference between the temperate of freezing and boiling water at sea level divided into 100 equal parts. Once such a standard is chosen, based upon that standard, a behavior could be considered right or wrong in (almost) any situation, often regardless of the behavior's consequences, and thus (almost) always be an obligation to carry out.
These methods (among others) can be used to formulate laws. The more real-world variables included and the less like a vacuum or a controlled laboratory environment an ethical dilemma is, the less the actual outcome may resemble the expected outcome. For an ethical system to be practical, it must be able to address variables and specific situations without a de novo analysis each time. It must also prevent extreme variety in outcomes by clinicians reaching different conclusions in identical situations.
Though it is not possible that normative ethics can be completely objective in the real world, attempts at maximizing an objective strategy for ethics can still be made, in an attempt at defying Hume's theory of emotivism, which is that ethics claims by their nature derive from emotion and not from fact.
Ethical Spectra and Biases
It is important when evaluating the stance of an authority to understand both its biases and if it has one, its primary objective standard (as defined above). For example, think about how differently HCPs of different specialties might approach fever workup and treatment due to not sharing a reference standard:
- Surgery: First line is to image to find something to lance and leave to open drainage
- Rheumatology: First line is to look for serum inflammatory markers and treat with steroids
- Infectious disease: First line is to obtain tissues for culture to allow treatment with a specific drug
- Interventional radiology: The first line is to image to find something to put a catheter in
- Primary care: The first line is to treat empirically with broad-spectrum antibiotics
- Organ specialty/hematology: The first line is to think about what non-infectious problems could cause fever in their tissue of choice
The AMA Code of ethics originators themselves can serve as an example of bias in ethics. The formation of the AMA occurred, at least in part to (1) prevent economic competition from "less qualified" medical practitioners and (2) to define the obligations of the public to physicians. The founders of the AMA maintained the bias of preventing racial minorities and women from practicing medicine.
Listed below are the spectra (biases) of the different major Conversationalists in ethics (not intended to be all-inclusive). Awareness of these standards/reference points can help a HCP perceive the variety of ethical views that he or she will encounter from patients, colleagues, and others.
Theories of Ethical Standards
- Egoism: Serve yourself first.
- Subjective relativism: Each person decides for oneself what interest to serve.
- Cultural relativism: Serve your society’s (or other social groups') expectations of you first.
- Utilitarianism: Serve the greatest good for the most people. Something is "good" if it is useful.
- Act utilitarianism vs. rule utilitarianism
- Act: Focus on the ends.
- Rule: Focus on means.
- Virtue ethics: Follow a defined list of virtues.
- Duty/deontological ethics: Whether or not your intentions/motives are good, act out of duty to the most relevant authority.
Medical ethics has included each of the above standards to different degrees in different times and places. A detailed discussion of these examples is beyond the scope of this article.
HCPs practicing medical ethics, from its ancient historical roots (in Egypt, Mesopotamia, and Greece) through the present day, have always primarily adhered to ethics of deontology, i.e., duty or obligation. The number of included duties is not magical or sacred; it differs depending on the source. Thomas Beauchamp (1939-) and James Childress (1940-) emphasized four, preferring to call them "principles" instead of "duties:"
- Nonmaleficence: "Not carrying badness," potentially the earliest written emphasis on ethics, can be traced particularly to the Egyptians.
- Beneficence: "Carrying good" can be traced to all early civilizations
- Respect for patient autonomy: "Self-rule," particularly stressed by Immanuel Kant; in some regards can be traced to the Greeks
- Distributive justice: Equality of rights among all persons; Equality in rights arguably may be traced to Guan Zhong (c. 650 BCE); in Western culture, it can be traced to the Stoics in thought, to first-century Christians in spiritual worth, and Thomas Hobbes in social rights.
Bernard Gert (1934-2011), Charles Culver (1934-2015), and Danner Clouser (1930-2000) provide a critical alternative to Beauchamp and Childress, both on a philosophical and on a practical level but also make many similar conclusions. They emphasize 10 duties for physicians:
- Do not kill.
- Do not cause pain.
- Do not disable.
- Do not deprive of freedom.
- Do not deprive of pleasure.
- Do not deceive.
- Keep your promises.
- Do not cheat.
- Obey the law.
- Do your duty.
Not altering Beauchamp and Childress' duties per se but also hoping to improve upon the practicality of their analysis, Albert Jonsen (1931-), Mark Siegler (1941-), and William Winslade (1941-) identified four topics intrinsic to every clinical encounter for organizing and prioritizing facts of a particular case:
- Medical indications: Diagnosis, prognosis, treatment options, physical treatment goals
- Patient preferences: Including patient values
- Patient quality of life: As experienced and determined by the patient
- Contextual features: Family, law, culture, hospital policy, insurance companies, other financial issues, among others.
The ACP ethics code includes Beauchamp and Childress's four principles by name. The 2016 AMA code defends all four principles to varying degrees. It does not address non-maleficence and beneficence using those terms but advises physicians to behave to maximize patient benefits and minimize harm. As mentioned previously, it emphasizes beneficence: "The practice of medicine... arises from the imperative... to alleviate suffering." The section on organ procurement supports distributive justice.
Although the AMA code shifted from using the language of “duties of physicians” in 1847 to “principles of medical ethics” in 1957, the code still implies that medical ethics are by nature shaped predominantly by duty (as opposed to by virtue or by utilitarianism).
Conflicts in Medical Ethics
Conflicts of interest in carrying out these duties are inherent to the profession and are the norm, not the exception. Conflict can occur between essentially any two ethical principles or duties. Numerous medical ethics texts explore these conflicts for a given clinical scenario, particularly conflicts between autonomy and beneficence, between distributive justice and beneficence, and between the "lesser of two evils" application of non-maleficence. The rest of this section will examine a much less commonly addressed conflict between beneficence and non-maleficence: not which is the lesser of two evils, but which is the greater good and which is more fundamental to the practice of medicine.
Beneficence is a Greater Good than and Primary to Non-Maleficence
Although non-maleficence serves as "out-of-bounds lines" in medicine, beneficence should remain cemented as the goal. This view directly opposes that of Gert, who argued that a physician has no moral obligation to be beneficent other than to meet whatever minimum duty of beneficence is required of the physician to keep his or her job. He argued that non-maleficence is morally obligatory but that beneficence of any kind is not. Gert was a very rational thinker but was neither a HCP nor a student of medical history, never delving into what HCPs of the past said in the Great Conversation. Gert's view contradicts thousands of years of medical practice, the current AMA position, and many people's moral compass as directed by their spiritual/religious convictions (discussed below).
The 2016 AMA code of ethics' opening line (i.e., its version of "Four score and seven years ago our fathers brought forth on this continent a new nation..." or "When, in the course of human events, it becomes necessary for one people to dissolve the political bonds which have connected them with another...") is:
"The practice of medicine, and its embodiment in the clinical encounter between a patient and a physician, is fundamentally a moral activity that arises from the imperative to care for patients and to alleviate suffering." (AMA code 1.1.1).
The text continues in the same vein about putting patients' health above the physicians' needs. There is no mention of any notion pertaining to "do no harm" until Section 1.1.7, and the authors of chapter 1 never fully develop the idea of non-maleficence. That the primary purpose of doctoring is altruism is supported by the Hippocratic Oath, in which "I will use treatment to help the sick according to my ability and judgment" precedes a discussion of avoiding harm. The concept "first do no harm" dates to Auguste Francois Chomel (1788-1858).
The mainstream perspective of natural law theorists, psychologists, and the public is that humans normally are expected to exhibit some beneficence (altruism). The controversy in law, philosophy, and business are how to defend rationally the degree to which beneficence is required.
An attempt to create an objective formula for when some human attempt at beneficence should be expected is:
A person (or group of people) P has an obligation to perform an act of beneficence aB to some other person Op whenever:
- Op is at risk R of significant loss of or damage to some basic interest.
- aB is definitely necessary or likely necessary to prevent R.
- aB does not present a significant R to P. In other words, The expected benefit to Op outweighs the expected burden to P.
Contrary to Gert's assertion that such behavior is not morally rational, this kind of behavior is supported by moral teaching in the form of a command, e.g., the parable of the Good Samaritan (Luke 10:25-37)..."Go and do likewise."
The notion that business persons' economic motivation commonly trumps their altruism is testified, not only by anyone who has ever "been taken advantage of" or experienced a glaringly inadequate "quality of service" by a business but also in ethics philosophy literature. Adam Smith was Hume's successor and influenced the field of business ethics. Smith (1723-1790) argued that the well-being of persons depends on social cooperation but not on businesses' benevolence to customers and that it is nonsensical to expect businesses to show benevolence. However, William Nickels (1939-) and Kellie McElhaney (1966-) have provided contemporary arguments that "charity" and "social responsibility," both forms of beneficence, are usually good for business (i.e., financial gain and influence) in the long run (analogous to some observations supported by game theory). Bartlett reviewed cost-benefit analyses of patient education techniques in a variety of settings and concluded that certain techniques in educating patients result in cost savings on a systems level. However, many HCPs do not educate patients because they receive no direct financial reward.
Persons like-minded to Gert believe that beneficence is nothing more than commendable. Some HCPs share this view or some version of it; their obligation is only to make some minimal effort to prevent harm but not even to attempt to relieve suffering. HCPs tend to exhibit this behavior/view as they evolve from their early days in medical training and obtain positions in which they are more concerned with money. Businesses and/or HCPs in authority that embrace the mantras of Smith and Gert not uncommonly go so far as directly to impede other HCPs from carrying out the very altruism that first inspired them to become HCPs.
Both the medical and military professions are also based on the ancient Greek virtue of "arete"- a commitment to excellence. Whereas the duty of the soldier is always foremost to protect his fellow soldiers, the duty of the HCP is always foremost to protect the patient. Persons who enter these professions often feel a "higher" calling to serve others that compels them to serve beyond meeting a minimum standard. Gert was married to his childhood sweetheart for over 50 years before being separated by death. Although a union of that sort can be achieved out of "duty," it usually requires and derives its meaning from another fundamental trait of humanity that can also be the driving force of a HCP's behavior: love (Greek "agape").
Gert convincingly argued that a person cannot impartially do good for all persons at all times. In this way, he unintentionally promoted distributive justice. Nevertheless, it is essentially unheard of to find a member of the Great Conversation, a statute of law, or an ethical code pertaining to the practice of medicine that argues that distributive justice dominates beneficence as a rule. Instead, the beneficence-justice dilemma is discussed only in the context of emergencies.
Unfortunately, Gert did not define how to carry out duty practically when there are opposing forces, specifically, a duty to the patient, to the nurse, to one's colleagues, to one's administrator, to one's medical student, and to one's risk manager. Codes of medical ethics indicate that the physician's duty to the patient supersedes the physician's duties to all others. Gert agreed that healthcare organization administrators should optimize physicians' time spent for beneficence while still meeting expectations of patients and policy requirements by using mid-level providers and/or assistants to, for example, reduce physician time spent on tasks not required for a physician to accomplish, such as patient education, data gathering, correspondence, procedure organization, and other logistics.
Proposed Hierarchy of Beneficence, Autonomy, Non-Maleficence, and Justice
- Proceed to do what you believe good for the patient, assuming that the patient agrees there is not a better option (beneficence and respect for autonomy).
- If the patient does not agree that your plan is the best option, then stop (respect for autonomy).
- If you or someone else is contemplating that you proceed to act in a way that you know could harm the patient, then stop (non-maleficence). The exception to this is if 1) the intent of the action that could harm the patient is beneficence 2) the plan of action is the least threatening/most desirable means to an end available (beneficence), and 3) the patient agrees with the action after having informed consent (respect for autonomy). If these three conditions are met, then proceed.
Ration beneficence evenly among patients (distributive justice); otherwise, proceed as for non-emergency settings.
Although successfully performing each of these tasks to the satisfaction of every patient is impossible, the AMA states the physician must make a good-faith attempt.
Medical Ethics' Link to Theology and Religion
Whereas writings on morals extend historically to the Egyptians before 2000 BCE, approaches to normative ethics began to act independently from the field of theology only around the mid-1700s. In other words, only in the last 5% to 10% of history has the approach to the public dissemination of mainstream moral thought involved taking God out entirely of the equation; a similar mainstream approach in medical ethics dates to an even later time. The major Greek philosophers (Aristotle) and Hippocratic physicians believed in a higher power than humanity. The 1847 AMA code drafting committee chairperson Dr. John Bell (1796-1872) wrote that "medical ethics, as a branch of general ethics, must rest on the basis of religion..." Dr. George Wood (1797-1879), AMA president in 1853, advised every physician to have access to the AMA ethics code because "next to Holy Scripture and the grace of God, it would serve most effectually to guard him from evil."
In 2017, over 70% of Americans identified as belonging to an Abrahamic religion (Christianity, Islam, and Judaism). About 2% identified as belonging to one of the other two major world religions of Hinduism or Buddhism, and about 6% identified as atheist or agnostic. At least approximately 20% of American hospital beds remain in a religion-affiliated hospital.
None of the primary principles of medical ethics either began with or are unique to Abrahamic writers. The norm in the United States is now enforcement of moral principles by secular authorizing bodies (government, professional societies, places of business). Nevertheless, it is historically inaccurate and incomplete to neglect the influence of a belief in God on the establishment of these principles, as argued by Friedrich Nietzsche (1844-1900). An informed application of the imperatives that modern medical ethics codes prescribe cannot exclude concepts from monotheistic theology and theodicy when applied to many patients. American HCPs routinely encounter patients and family members who ascribe ethical authority to texts that they believe come with directives from God and often serve as their highest ethical authority.